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06/&5/2003 08:35 77535844 <br />LA PERKS 6 <br />PAGE 08 <br />Page k of Z <br />Secondary Containment 'Testing Report Form <br />This form is intendedfor use by contractorsperfornungperiodic testing of UST secondary containment systems. Use the appropriate <br />pages of this fbrm to report resultsfor all components tested Ae completed form, written test procedu vs, and printouts from tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory ageruy. <br />Number of Tars Tested: 0 <br />Number of Submersible Pump <br />Number of Fill Sumps Tested:0 <br />3. SUMMARY OF TEST RESULTS <br />Number of Piping Runs Tested'0 <br />Tested:0 Number of UDC Boxes Tested:0 <br />Number of Overfill Boxes Tested:Z <br />Component Pass Fail Comments <br />87 fill X ❑ <br />91 fill ❑ X Fill needs drain replaced <br />,❑ ❑ <br />❑ ❑ <br />0 ❑ <br />❑ ❑ <br />Q ❑ <br />0 ❑ <br />d a <br />D ❑ <br />❑ ❑ <br />❑ ❑ <br />a a <br />Technician's Signature:. <br />SWRCB <br />Date: 5/19/0 <br />